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		<div class="textC font1-4">压疮风险评定细则</div>
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					<div class="project">1.感知：</div>
						<span class="instuction">①没有改变：</span>
							<span>机体没有感觉缺失。</span>
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						<span class="instuction">②轻度受限：</span>
							<div class="otherYaChuang">对说话有反应,一到两个肢体对疼痛或不适感感觉障碍。</div>
						<span class="instuction">③非常受限：</span>
							<div class="otherYaChuang">只对疼痛刺激有反应，能通过呻吟或烦躁表达机体不适，或机体一半以上的部位对疼痛或不适感感觉障碍。</div>
						<span class="instuction">④完全受限：</span>
							<span>对疼痛刺激没有反应。</div>
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					<div class="project">2.潮湿：</div>
						<span class="instuction">①很少潮湿：</span>&nbsp;&nbsp;<span>皮肤通常是干的，只需常规更换床单。</span>
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						<span class="instuction">②偶尔潮湿：</span>&nbsp;&nbsp;<span>每天大概需要额外换一次床单。</span>
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						<span class="instuction">③非常潮湿：</span>&nbsp;&nbsp;<span>床单每天至少换一次。</span>
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						<span class="instuction">④持久潮湿：</span>&nbsp;&nbsp;<span>皮肤一直处于潮湿状态。</span>
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					<div class="project">3.活动能力：</div>
						<span class="instuction">①经常步行：</span>
							<div class="otherYaChuang">每天至少2次室外行走，白天醒着的时候至少每2小时行走一次。</div>
						<span class="instuction">②偶尔步行：</span>
							<div class="otherYaChuang">偶尔可走一段路，每天大部分时间在床上或轮椅上。</div>
						<span class="instuction">③局限轮椅：</span>
							<span>行动能力严重受限或没有行走能力。</span>
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						<span class="instuction">④卧床不起：</span>
							<span>局限在床上。</span>
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					<div class="project">4.移动能力：</div>
						<span class="instuction">① 不 受 限：</span>&nbsp;&nbsp;<span>独立完成经常性的大幅度体位改变。</span>
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						<span class="instuction">②轻度受限：</span>
							<div class="otherYaChuang">能经常独立地改变躯体或四肢位置，变动幅度不大。</div>
						<span class="instuction">③严重受限：</span>&nbsp;&nbsp;<span>偶尔能轻微移动躯体或四肢。</span>
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						<span class="instuction">④完全受限：</span>
							<div class="otherYaChuang">没有帮助不能完成轻微的躯体或四肢的位置变动。</div>
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					<div class="project">5.营养：</div>
						<span class="instuction">①摄入良好：</span>
							<div class="otherYaChuang">每餐摄入绝大部分食物从来不拒绝食物，不需要其他补充食物。</div>
						<span class="instuction">②摄入适当：</span>
							<div class="otherYaChuang">可摄入供给量的一半以上，或管饲或TPN能达到绝大部分营养所需。</div>
						<span class="instuction">③可能摄入不足：</span>
							<div class="otherYaChuang02">只能摄入所给食物的1/2或可摄入略低于理想量的流质或管饲。</div>
						<span class="instuction">④重度摄入不足：</span>
							<div class="otherYaChuang02">从不能吃完一顿饭，很少能摄入所给实物量的1/3，很少摄入液体，没有摄入流质饮食，或着禁食或静脉输入大于5天。</div>
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					<div class="project">6.摩擦与剪切能力：</div>
						<span class="instuction">①无明显问题： </span>
							<div class="otherYaChuang03">能独立在床上或椅子上移动，并可在移动时完全抬高躯体。</div>
						<span class="instuction">②有潜在问题：</span>
							<span class="otherYaChuang04">移动过程中，皮肤一定程度上会碰到床单。</span>
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						<span class="instuction">③已成为问题：</span>
							<span class="otherYaChuang04">不可能做到完全不碰到床单。</span>
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